But the service, and thousands like it across the USA, can't ignore the bottom line -- not when the fire district projects a $1.5 million drop in property tax revenue next year. So on Sept. 1, the tax-funded district raised its ambulance fees, hiking its basic service from $375 to $550. "We're not here to make a profit," Berlin says. "The only thing we can do is try to improve our service -- or maintain it."

Ambulance providers are coping with rising costs, decreased government support, low Medicare reimbursement rates and a jump in the number of uninsured Americans, says Stephen Williamson, president of the American Ambulance Association.

A 2007 report by the Government Accountability Office showed providers were paid a Medicare reimbursement rate 6% below cost, and the gap widened to 17% in remote areas. Williamson says the disparity has grown since then, and subsidies from local government have dwindled during the economic downturn.

Steve Weigand, director of servicing for the International Association of EMTs and Paramedics, says the number of uninsured people receiving ambulance transport has swelled during the past 18 to 24 months. "We're having to raise the rate on everyone else because of the people who don't have insurance," Weigand says.

Los Angeles. The city's fire department increased its ambulance prices by nearly 37% to $974 for basic life support services in July, the second hike in two years, says David Frelinger, a battalion chief in the emergency medical services section.

Even when ambulance providers increase their rates, they often get only a fraction of the full payment, says Cathy Carter, president of Medical Claim-Aid in Denton, Md., which provides billing and collection services for ambulance providers in Maryland, West Virginia and Virginia.

Medicare and Medicaid pay a fixed amount, based on set rates that are below the cost of ambulance transports, she says. In some cases, private insurers have stopped reimbursing ambulance providers and send payment to the patient, she says, and that person often pockets the money.